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. Author manuscript; available in PMC: 2020 Aug 1.
Published in final edited form as: Addict Behav. 2019 Apr 2;95:202–205. doi: 10.1016/j.addbeh.2019.04.001

Greater perceived importance of earning abstinence-contingent incentives is associated with smoking cessation among socioeconomically disadvantaged adults

Adam C Alexander 1, Emily T Hébert 1, Michael S Businelle 1,2, Darla E Kendzor 1,2
PMCID: PMC6545141  NIHMSID: NIHMS1526500  PMID: 30959415

Abstract

Background.

Individuals’ perceptions of the importance of earning financial incentives for smoking cessation may influence the effectiveness of contingency management interventions. This study prospectively explored the perceived importance of earning financial incentives for smoking cessation and its association with smoking cessation within a contingency management intervention among socioeconomically disadvantaged adults.

Methods.

This study is a secondary analysis of data from a randomized clinical trial that recruited socioeconomically disadvantaged adults from a safety-net hospital in Dallas County, Texas, from 2011 to 2013. Participants, who were randomly assigned to receive small financial incentives for smoking abstinence (N=75), rated the importance of earning abstinence-contingent financial incentives one day after their scheduled quit day and one-week post-quit day. Self-reported smoking abstinence was biochemically confirmed weekly through the fourth week post-quit day and at the twelfth week post-quit day. Participants were considered continuously abstinent if self-reported abstinence since the quit date was biochemically confirmed.

Results.

Greater perceived importance of earning abstinence contingent incentives for smoking cessation was associated with a higher likelihood of achieving continuous abstinence during the four-week intervention period (OR = 3.95 [95% CI = 1.64, 9.53]) and through 12 weeks post-quit day (OR = 4.71 [95% CI = 1.56, 14.26]).

Conclusions.

Findings suggest that the perceived importance of earning abstinence-contingent incentives early in a quit attempt predicts smoking cessation among socioeconomically disadvantaged adults and may indicate whether an individual will be responsive to the magnitude of incentives offered.

Keywords: Perceptions, Smoking, Incentives, Poverty, Cessation, Minorities

INTRODUCTION

Most adults who smoke cigarettes want to quit smoking, but only 7% succeed each year, and the chances of quitting are much lower among adults of low socioeconomic status (SES; Babb, Malarcher, Schauer, Asman, & Jamal, 2017). Numerous studies have shown that contingency management (CM) interventions increase smoking cessation among adults of low SES (Baggett et al., 2017; Businelle et al., 2014; Kendzor et al., 2015; Lasser et al., 2017), and that the opportunity to earn financial incentives for smoking cessation is appealing within this group (Bonevski, Bryant, Lynagh, & Paul, 2012; Sindelar & O’Malley, 2014). Findings from two meta-analyses indicate that financial incentives are associated with higher odds of behavior change particularly among low SES adults (Haff et al., 2015; Mantzari et al., 2015). Nevertheless, many adults fail to quit smoking even when they participate in a CM intervention, and more studies are needed to understand how CM interventions can be refined for optimal cessation outcomes.

Plausibly, the perceived importance of earning abstinence-contingent financial incentives may influence the likelihood that a CM intervention, particularly the magnitude of incentives offered, will be effective. Participants who value the incentives that are offered may be more motivated to remain abstinence from smoking. For example, Kim et al. (2011) found that CM participants who successfully quit smoking for 1-year were more likely to perceive that financial incentives were important for motivating their quit attempt than participants who failed to quit smoking. However, perceptions were measured after completing the 1-year intervention, and the study was conducted in a sample of adults earning a stable income with 65% earning at least 500% of the poverty threshold (Kim, Kamyab, Zhu, & Volpp, 2011; Volpp et al., 2009). These findings may be less generalizable to people of low socioeconomic status who may smoke to cope with financial and numerous other stressors (Kalkhoran, Berkowitz, Rigotti, & Baggett, 2018; Kendzor et al., 2010).

This study extends previous findings by exploring the prospective relations between the perceived importance of earning abstinence-contingent financial incentives with 1) smoking cessation outcomes and 2) total incentive earnings among socioeconomically disadvantaged adults making a smoking cessation attempt. Assessing the importance of earning abstinence-contingent incentives may provide insight early in treatment about the likelihood that participants will be responsive to the intervention and incentive magnitudes. Based on prior literature, participants who place greater importance on earning incentives may earn more abstinence-contingent financial incentives and have higher cessation rates than those who place less importance on earning incentives.

METHODS

Refer to Kendzor et al. (2015) for a full description of the smoking cessation intervention. Briefly, adult cigarette smokers were recruited during their orientation visit to the Tobacco Cessation Clinic at the Dallas County, Texas, safety net hospital between August 2011 and April 2013. Participants (N = 153) were randomly assigned to receive either pharmacotherapy and counseling sessions (i.e., usual care) or usual care with small financial incentives for smoking abstinence (i.e., CM). The CM condition earned a $20 gift card for self-reported and carbon monoxide (CO)—confirmed abstinence on their scheduled quit date (i.e., overnight abstinence), and the gift card incentive increased by $5 each week for every successive biochemically-confirmed abstinent visit (i.e., abstinent for the previous 7 days) up to the fourth week after their scheduled quit date (up to $150 total). Participants who were smoking at any visit were eligible to earn incentives for abstinence at the next visit, although the amount was reset to $20. Only participants assigned to the CM condition (N = 75) were included in the current study.

Measures

Independent variable.

The perceived importance of earning financial incentives for smoking cessation was measured by asking participants a single question one day after their scheduled quit day and again, one week after the quit day: “How important has it been for you to earn the payment for smoking abstinence?” Participants chose from the following response options: not at all, somewhat, very, and extremely important. Responses on both questions were moderately correlated (r = .67, p < .01).

Dependent variables.

There were three dependent variables: 1) the total dollar value of abstinence-contingent incentives earned in the form of gift cards and 2) biochemically-confirmed continuous abstinence from quit day through 4 and 12 weeks post-quit day. Abstinence-contingent incentives were summed across five weekly visits from the quit day through 4 weeks post-quit, and earnings ranged from $0-$150.

Expired CO levels were measured to confirm self-reported smoking status. A cut-point of 8–10 ppm distinguishes smoking versus not smoking with a sensitivity and specificity of approximately 90% (Benowitz et al., 2002). On the scheduled quit day, smoking abstinence was defined as self-reported abstinence from smoking since 10 pm the evening prior in combination with an expired CO level of ≤ 10 ppm (given the recency of cessation). After the quit day, participants were considered abstinent if they self-reported abstinence from smoking over the past seven days and had an expired CO level of ≤ 7 ppm.

Participants were considered continuously abstinent at 4 and 12 weeks post-quit-day if they reported that they had been abstinent since the quit day (with a 12-hour grace period) and demonstrated a corroborating CO level at all attended visits. Participants who self-reported abstinence since the quit date but had missing smoking status data at some visits due to non-attendance were considered continuously abstinent if they missed no more than two consecutive assessments and the data at the surrounding visits indicated abstinence.

Covariates.

Covariates in multivariable analyses included baseline race/ethnicity, sex, age, education, nicotine dependence (e.g., heaviness of smoking index [HSI]), insurance and employment status, and subjective social status (SSS), which was assessed using the MacArthur Scale of SSS (Adler, Epel, Castellazzo, & Ickovics, 2000). The MacArthur Scale of SSS scale depicts a 10-rung ladder, with higher rungs representing the individual’s perception of themselves as having higher income, education, and occupational prestige relative to their peers (Adler et al., 2000). Smoking status, on the scheduled quit day or one week post-quit day, was also included as a covariate to account for the influence that behavior has on perceptions (Webb & Sheeran, 2006).

Statistical analyses

Descriptive statistics were generated for independent and dependent variables and covariates. Ordinal logistic regression was used to identify sociodemographic factors that were associated with perceptions of the importance of earning financial incentives for smoking cessation. Next, univariate and multivariable linear and logistic regressions were conducted to explore the associations between the perceived importance of earning abstinence-contingent financial incentives and the (1) total dollar amount of abstinence-contingent incentives earned, and (2) continuous smoking abstinence through four and twelve weeks post-quit date. All analyses used a significance level of 0.05. Participants with inadequate data to calculate continuous abstinence were considered smoking (i.e., intent-to-treat; see Kendzor et al. 2015 for additional details) and ≤ 3% of data points were missing for other explanatory variables in the primary analyses. All analyses were performed using SAS version 9.4 (SAS, 2013).

RESULTS

As shown in Table 1, participants in the CM condition (N = 75) were on average 51.75 (SD = 7.28) years of age, were mostly female (53.33%) and Black or African American (66.67%), and on average, had 11.94 (SD = 2.20) years of education. Many participants were uninsured (42.67%), and 89.33% of participants were unemployed. Participants on average placed themselves on the 4th rung on the 10-rung SSS ladder (M = 4.36, SD = 2.04), indicating that they ranked themselves low in social standing, and one week before the quit-date, participants had an average HSI score of 3.36 (SD = 1.34), which indicated moderate nicotine dependence.

Table 1.

Sample characteristics (N = 75)

Characteristic Mean (SD) or N (%)
Age (years) 51.75 (SD = 7.28)
Sex (% Female) 40 (53.33%)
Race/Ethnicitya (% Non-White) 54 (72.00%)
Education (years) 11.94 (SD = 2.20)
Subjective social status 4.36 (SD = 2.04)
Insurance status (% uninsured) 32 (42.67%)
Employment status (% not employed)b 67 (89.33%)
How important has it been for you to earn the payment for smoking abstinence? (1 day after the quit-date)
 Not at all important 17 (22.67%)
 Somewhat important 23 (30.67%)
 Very important 15 (20.00%)
 Extremely important 18 (24.00%)
 Missing 2 (2.67%)
How important has it been for you to earn the payment for smoking abstinence? (1-week post-quit date)
 Not at all important 15 (20.00%)
 Somewhat important 28 (37.33%)
 Very important 11 (14.67%)
 Extremely important 21 (28.00%)
Total compensation received from abstinence-contingent incentives ($) $63.40 (SD = 51.67)
Heaviness of smoking index (HSI) 3.36 (SD = 1.34)
Biochemically verified smoking abstinence
 1 day after the quit date 58 (77.33%)
 1 week post-quit date 35 (46.67%)
Biochemically verified continuous smoking abstinence
 4 weeks post-quit date 19 (25.33%)
 12 weeks post-quit datec 13 (17.33%)
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a

Whites (n = 21); African Americans (n = 50); more than one race (n = 4).

b

Regular full-time work (40 or more hours per week; n = 2), regular part-time work (less than 40 hours per week; n = 6), unemployed - currently looking for work (n = 8), unemployed -currently not looking for work (n = 5), homemaker-not employed (n = 3), student -not employed (n = 2), retired-not employed (n = 6), unable to work or disable (n = 40), and other (n = 3).

c

Only a subsample (n = 64) were offered the opportunity to complete the follow-up visit at 12 weeks after the quit date.

One day after the quit date, 22.67% of participants reported that earning payments for smoking abstinence was not at all important, 30.67% reported that it was somewhat important, 20% reported that it was very important, and 24% reported that it was extremely important (see Table 1). An ordinal logistic regression analysis indicated that participants of greater age were less likely than those of younger age to report greater importance of earning abstinence-contingent incentives for smoking cessation (OR = 0.92 [95% CI = 0.86, 0.99]). Also, women, compared to men, were more likely to report greater importance of earning abstinence-contingent incentives for smoking cessation (OR = 3.84 ([95% CI = 1.48, 9.93]; see supplementary materials for additional details).

Linear regression analyses (also see Figure 1) indicated that greater perceived importance of earning abstinence-contingent incentives was associated with earning more incentives during the 4-week intervention period (B = 16.17, SE = 5.67, p = .01). Further, logistic regression analyses indicated that greater perceived importance of earning the abstinence-contingent incentives was associated with higher odds of continuous abstinence four (OR = 3.95 [95% CI = 1.64, 9.53]) and 12 (OR = 4.71 [95% CI = 1.56, 14.26]) weeks after the scheduled quit-date (see supplementary materials).

Figure 1.

The association between the perceived importance of earning financial incentives for smoking cessation with average incentives earned and continuous smoking abstinence at 4 and 12 weeks following the quit date.

Figure 1.

Note: Adjusted analysis controlled for race/ethnicity (non-Hispanic White vs. Hispanic or non-White), sex (female vs. male), age, years of education, nicotine dependence (e.g., heaviness of smoking index), and insurance (uninsured vs. insured) and employment status (disabled/unable to work vs. all others), subjective social status, and smoking status.

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DISCUSSION

This study explored perceptions of the importance of earning abstinence-contingent incentives, and their relation to total incentive earnings and smoking cessation outcomes. Overall, findings suggested that people who placed greater importance on earning abstinence contingent payments early in a quit attempt earned more incentives throughout the 4-week intervention period and were more likely to remain continuously abstinent up to 12 weeks after the scheduled quit day. Further, findings indicated that women and younger adults placed greater importance on earning the small abstinence-contingent incentives that were offered in this intervention, compared to males and older adults.

Although research has shown that incentive magnitude is positively associated with the likelihood of smoking cessation (e.g., Packer, Howell, McPherson, & Roll, 2012), a more tailored approach would allow interventionists to offer the lowest value incentive that would be motivating for an individual participant, thereby promoting both cost-effectiveness and effectiveness. Nevertheless, it may not always be economically feasible to increase the value of incentives. Alternatively, monetary rewards could be linked with personal life goals, values, or aspirations (Kullgren et al., 2016). For instance, participants could be asked to describe and reflect upon how they might use their financial rewards to achieve their personal goals, such as becoming a better parent or saving money for a vacation. At the very least, it may be useful to know at the start of treatment whether or not the individual is likely to benefit from the CM approach, and particularly the value of the incentives that are being offered. If not, then alternative approaches may be more appropriate.

Many participants reported that earning payments for smoking abstinence was not at all or only somewhat important (57%) for smoking abstinence. Reitzel and Leventhal (2014) found that even when offered small financial incentives not to smoke for a short period (50 minutes), people of lower SES, particularly those who never attended college, had a reduced willingness to delay smoking for money compared to higher SES counterparts. Perhaps people who perceive abstinence-contingent financial incentives as less important may place a higher value on smoking, with the benefits of smoking outweighing the benefits of earning abstinence-contingent financial incentives.

This study demonstrates that the extent to which participants value abstinence-contingent incentives impacts their likelihood of successful smoking cessation. Results suggest that financial incentives interventions may be enhanced by actively targeting perceptions about the importance of earning incentives for smoking cessation, by increasing the monetary reward offered for smoking cessation, or by tailoring the monetary reward to reflect personal life goals, values, and aspirations (Kullgren et al., 2016). Limitations of the study include the small sample size and the use of less stringent CO thresholds for abstinence that were common when the data were collected. Nevertheless, assessing the importance to participants of earning the specific incentive values offered, may allow for tailored CM enhancements that increase treatment effectiveness.

Supplementary Material

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Highlights.

  • Women and young adults think it is important to earn money for smoking cessation.

  • The perceived importance of earning money for quitting tobacco predicts abstinence.

  • These adults may be the best candidates for incentives-based cessation treatment.

Footnotes

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REFERENCES

  1. Adler NE, Epel ES, Castellazzo G, & Ickovics JR (2000). Relationship of subjective and objective social status with psychological and physiological functioning: Preliminary data in healthy, White women. Health Psychology, 19(6), 586–592. 10.1037/0278-6133.19.6.586 [DOI] [PubMed] [Google Scholar]
  2. Babb S, Malarcher A, Schauer G, Asman K, & Jamal A (2017). Quitting Smoking Among Adults — United States, 2000–2015. MMWR. Morbidity and Mortality Weekly Report, 65(52), 1457–1464. 10.15585/mmwr.mm6552a1 [DOI] [PubMed] [Google Scholar]
  3. Baggett TP, Chang Y, Yaqubi A, McGlave C, Higgins ST, & Rigotti NA (2017). Financial Incentives for Smoking Abstinence in Homeless Smokers: A Pilot Randomized Controlled Trial. Nicotine & Tobacco Research. 10.1093/ntr/ntx178 [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Benowitz NL III, P J, Ahijevych K, Jarvis MJ, Hall S, LeHouezec J, … Velicer W (2002). Biochemical verification of tobacco use and cessation. Nicotine & Tobacco Research, 4(2), 149–159. 10.1080/14622200210123581 [DOI] [PubMed] [Google Scholar]
  5. Bonevski B, Bryant J, Lynagh M, & Paul C (2012). Money as motivation to quit: A survey of a non-random Australian sample of socially disadvantaged smokers’ views of the acceptability of cash incentives. Preventive Medicine, 55(2), 122–126. 10.1016/j.ypmed.2012.06.001 [DOI] [PubMed] [Google Scholar]
  6. Businelle MS, Kendzor DE, Kesh A, Cuate EL, Poonawalla IB, Reitzel LR, … Wetter DW (2014). Small financial incentives increase smoking cessation in homeless smokers: A pilot study. Addictive Behaviors, 39(3), 717–720. 10.1016/j.addbeh.2013.11.017 [DOI] [PubMed] [Google Scholar]
  7. Haff N, Patel MS, Lim R, Zhu J, Troxel AB, Asch DA, & Volpp KG (2015). The Role of Behavioral Economic Incentive Design and Demographic Characteristics in Financial Incentive-Based Approaches to Changing Health Behaviors: A Meta-Analysis. American Journal of Health Promotion, 29(5), 314–323. 10.4278/ajhp.140714-LIT-333 [DOI] [PubMed] [Google Scholar]
  8. Kalkhoran S, Berkowitz SA, Rigotti NA, & Baggett TP (2018). Financial Strain, Quit Attempts, and Smoking Abstinence Among U.S. Adult Smokers. American Journal of Preventive Medicine, 55(1), 80–88. 10.1016/j.amepre.2018.01.036 [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Kendzor DE, Businelle MS, Costello TJ, Castro Y, Reitzel LR, Cofta-Woerpel LM, … Wetter DW (2010). Financial strain and smoking cessation among racially/ethnically diverse smokers. American Journal of Public Health, 100(4), 702–706. 10.2105/AJPH.2009.172676 [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Kendzor DE, Businelle MS, Poonawalla IB, Cuate EL, Kesh A, Rios DM, … Balis DS (2015). Financial Incentives for Abstinence Among Socioeconomically Disadvantaged Individuals in Smoking Cessation Treatment. American Journal of Public Health, 105(6), 1198–1205. 10.2105/AJPH.2014.302102 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Kim A, Kamyab K, Zhu J, & Volpp K (2011). Why are financial incentives not effective at influencing some smokers to quit? Results of a process evaluation of a worksite trial assessing the efficacy of financial incentives for smoking cessation. Journal of Occupational and Environmental Medicine, 53(1), 62–67. 10.1097/JOM.0b013e31820061d7 [DOI] [PubMed] [Google Scholar]
  12. Kullgren JT, Williams GC, Resnicow K, An LC, Rothberg A, Volpp KG, & Heisler M (2016). The promise of tailoring incentives for healthy behaviors. International Journal of Workplace Health Management, 9(1), 2–16. 10.1108/IJWHM-12-2014-0060 [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Lasser KE, Quintiliani LM, Truong V, Xuan Z, Murillo J, Jean C, & Pbert L (2017). Effect of Patient Navigation and Financial Incentives on Smoking Cessation Among Primary Care Patients at an Urban Safety-Net Hospital. JAMA Internal Medicine, 177(12), 1798 10.1001/jamainternmed.2017.4372 [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Mantzari E, Vogt F, Shemilt I, Wei Y, Higgins JPT, & Marteau TM (2015). Personal financial incentives for changing habitual health-related behaviors: A systematic review and meta-analysis. Preventive Medicine, 75, 75–85. 10.1016/j.ypmed.2015.03.001 [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Packer RR, Howell DN, McPherson S, & Roll JM (2012). Investigating reinforcer magnitude and reinforcer delay: A contingency management analog study. Experimental and Clinical Psychopharmacology, 20(4), 287–292. 10.1037/a0027802 [DOI] [PubMed] [Google Scholar]
  16. Reitzel LR, & Leventhal AM (2014). Socioeconomic Status and the Reward Value of Smoking Following Tobacco Abstinence: A Laboratory Study. Nicotine & Tobacco Research, 16(11), 1455–1462. 10.1093/ntr/ntu100 [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. SAS. (2013). Base SAS 9.4 Procedures Guide (SEcond). NC: SAS Institute; 10.1016/0370-2693(82)91293-X [DOI] [Google Scholar]
  18. Sindelar JL, & O’Malley SS (2014). Financial versus health motivation to quit smoking: A randomized field study. Preventive Medicine, 59, 1–4. 10.1016/j.ypmed.2013.10.008 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Volpp KG, Troxel AB, Pauly MV, Glick HA, Puig A, Asch DA, … Audrain-McGovern J (2009). A Randomized, Controlled Trial of Financial Incentives for Smoking Cessation . New England Journal of Medicine, 360(7), 699–709. 10.1056/NEJMsa0806819 [DOI] [PubMed] [Google Scholar]
  20. Webb TL, & Sheeran P (2006). Does changing behavioral intentions engender behavior change? A meta-analysis of the experimental evidence. Psychological Bulletin, 132(2), 249–268. 10.1037/0033-2909.132.2.249 [DOI] [PubMed] [Google Scholar]

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Supplementary Materials

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NIHMS1526500-supplement-1.docx (21.3KB, docx)

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